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When a manager reports: taking action for client safety

Case study about duty to report

​​​​​Karen puts down the file she's been reviewing and sighs.  Once again there's a complaint about Janine's documentation. As the nurse manager of the High Acuity Unit, Karen has become increasingly concerned about Janine's failure to document appropriately on her clients. ​​​


Six months ago, staff began complaining about coming on shift after Janine because her documentation and handover reports often lacked the detail necessary for staff to get a full picture of a client's status. 

Karen's initial review validated these complaints and she followed up with Janine informally on several occasions. Despite these discussions, Karen received yet another complaint about Janine. After some investigation Karen discovered that on one particular shift, Janine had not documented on any of her clients. This made it difficult for oncoming staff to provide the urgent care required and put three clients at risk of harm.

During the employer review that followed, Karen clarified expectations and explored contributory factors with Janine. She then met with Janine and reviewed documentation policies, provided additional resources and requested Janine develop a learning plan with the clinical nurse educator. She also put limits on Janine's practice for the next four weeks, requiring her to work under supervision and have her documentation reviewed.

Are clients at risk?

Now, two months later, she's investigating another serious incident where Janine's lack of documentation and inadequate handover put a client at risk of harm.

Karen reviews the evidence collected during the investigations: documentation of incidents, emails outlining concerns, and related safety event reports. These provide specific details of the incidents, actions taken, and any harm or risk of harm to clients. This evidence helps Karen recognize that Janine's behaviour is a repeated pattern that continues to put clients at risk of harm. She notes that Janine has still not provided a learning plan and instead states that unit issues, such as lack of team work and support from others, are causing the problems.   

What is Karen's responsibility?

Karen knows her first duty is to protect clients by making sure her staff provides safe care. She's investigated the complaints about Janine's practice and determined that she needs to take steps to ensure client safety. After a second employer review, Janine is removed from clinical care until she completes her learning plan. Karen will continue to work with Janine to remediate her practice, and/or use progressive discipline to address the concerns.  She may also involve others (workplace health, union representative) to determine what may be contributing to Janine's practice issues.

Does Karen have a duty to report Janine to CRNBC?

Based on her review of the evidence, Karen believes that Janine's continued practice may contribute to unsafe care and could result in client harm. In this situation, Karen does have a duty to report to CRNBC. The Health Professions Act and Duty to Report practice standard require her to report if she has reasonable and probable grounds based on evidence that Janine's continued practice might constitute a danger to the public.

How does Karen make a complaint to CRNBC?

Karen contacts CRNBC and speaks with the Nursing Concerns Coordinator. She learns that the complaint needs to be written and must contain enough clear and specific detail to enable CRNBC to evaluate the information and know what specifically to investigate. She doesn't however, need to identify which standards she believes may have been breached. 

Karen writes a letter of complaint outlining the incidents that lead her to believe clients are at continued risk of harm. She includes a detailed description of each incident, the evidence she believes exists, as well as the negative impact and risk to clients.  She describes Janine's response to these concerns when raised by the employer. Karen also outlines the steps she has taken to limit the risk she believes Janine's practise poses, first by requiring that she work under supervision, then by removing her from clinical care until she completes her learning plan.

She submits the written complaint to CRNBC's Nursing Concerns Coordinator.

Read the Letter of Complaint 

More about submitting a complaint to CRNBC and the complaints review process

​Ask yourself

  • ​If you were Karen, what would you do?
  • ​​Have you ever been in a similar situation?​​

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